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Stevens-Johnson syndrome occurrence associated with nevirapine
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Stevens-Johnson syndrome was rare in an HIV clinic in Mbabane, Swaziland; however, of those that occurred, 84% were associated with nevirapine, according to recent study findings published in The Pediatric Infectious Disease Journal.
“Over 100 documented drugs have been implicated as causes of [Stevens-Johnson syndrome], with trimethoprim-sulfamethoxazole and nevirapine having relatively high risks, especially in patients infected with HIV,” researchers wrote.
The study included 19 cases of Stevens-Johnson syndrome in patients aged younger than 20 years. Researchers also collected patient demographic, immunosuppression and outcome data.
Of the cases that were not associated with nevirapine, 11% were caused by TMP-SMX and 5% by efavirenz. Median symptom onset occurred 22 days after medication initiation.
When Stevens-Johnson syndrome was diagnosed, 84% had advanced or severe immunosuppression, 42% required hospitalization, and no Stevens-Johnson syndrome associated deaths were known to occur. Efavirenz use was attempted in eight of the nevirapine associated cases after Stevens-Johnson syndrome was resolved, and all were successful except one.
“While it is reported that [nevirapine] has a high association with [Stevens-Johnson syndrome], the overall occurrence in this setting was low, likely due to careful monitoring,” researchers wrote. “While the risk of [Stevens-Johnson syndrome] is real, informed providers can mitigate much of the morbidity and mortality through correct use of lead-in dosing when appropriate, clear anticipatory guidance for clinic return at onset of symptoms, and prudent discontinuation when a severe reaction appears to be developing (such as any blistering or bullae formation or any involvement of mucosa).”
Disclosure: The study was supported by the Baylor International Pediatric AIDS Initiative and Texas Children’s Hospital.
Perspective
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Elizabeth McFarland, MD
Dr. Dziuban and colleagues have characterized drug-associated Stevens Johnson Syndrome (SJS) in cohort of HIV-infected pediatric patients. Since this complication is rare but serious, therefore it is valuable to clinicians to have a point of reference by which to assess the relative severity and expected course if one of their own patients suffers from SJS. This study provides such information that will assist clinicians in their care and in counseling patients.
We learn from this report that just under half of the cases had onset of SJS rash during the lead-in dosing period; thus caution is required during this phase as well as in the early days of full dose administration. Fortunately, as described, the majority of cases occur within a month of treatment initiation, which is helpful to clinicians both in terms of how long to be especially vigilant but also in assessing the likelihood of a chronic medication resulting in late onset of SJS. Of note, 4 of the 19 cases were successful in replacing nevirapine (NVP) with efavirenz (EFV). Although it may be wise to avoid this switch when possible, it is useful to note that rash with NVP does not need to be an absolute contraindication to EFV.
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